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Full Name
(Required)
Phone
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Email
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Eligibility Questionnaire
Are you male or female?
(Required)
Select Male or Female
Genetically Male
Genetically Female
What is your age?
(Required)
What is your current weight?
(Required)
What is your Current height?
(Required)
3'0
3'1
3'2
3'3
3'4
3'5
3'6
3'7
3'8
3'9
3'10
3'11
4'0
4'1
4'2
4'3
4'4
4'5
4'6
4'7
4'8
4'9
4'10
4'11
5'0
5'1
5'2
5'3
5'4
5'5
5'6
5'7
5'8
5'9
5'10
5'11
6'0
6'1
6'2
6'3
6'4
6'5
6'6
6'7
6'8
6'9
6'10
6'11
7'0
Your BMI (Body Mass Index)
What is your weight loss goal?
(Required)
General Questions
Do you have diabetes?
(Required)
Select Yes or No
Yes
No
Are you currently on insulin?
Select Yes or No
Yes
No
What Type of Diabetes do you have?
Select Type 1 or Type 2
Type 1
Type 2
Are you currently pregnant, breastfeeding, or planning to become pregnant?
(Required)
Select Yes or No
Yes
No
Not Applicable
Are you currently practicing a birth control method or perimenopausal?
(Required)
Select Yes, No or Non Applicable
Yes
No
Not Applicable
Are you planning to travel soon?
(Required)
Select Yes or No
Yes
No
Have you had any recent lab tests?
(Required)
Select Yes or No
Yes
No
Please Specify:
Please list your Allergies
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Do you have any known allergies?
(Required)
Select Yes or No
Yes
No
Current Medications
Are you currently taking any of these medications or supplements?
(Required)
Antacids
Androgens
Thyroid Medications (e.g., Levothyroxine)
NSAIDs (e.g., Ibuprofen, Naproxen)
Corticosteroids (e.g., Prednisone)
Anticoagulants (e.g., Warfarin)
Hormonal Medications (e.g., Birth Control Pills, Hormone Replacement Therapy)
Cancer Medications (specifically those affecting hormone-sensitive cancers)
Insulin or Insulin Secretagogues (e.g., Sulfonylureas)
Oral Diabetes Medications (e.g., Metformin)
Medications that Slow Gastrointestinal Motility (e.g., Anticholinergics)
Diuretics
None of the above
Current Conditions
Please select any conditions you have from the list below
(Required)
Kidney disease
Liver disease
Gallbladder disease
Uncontrolled Diabetes
Polycystic Ovary Syndrome (PCOS)
Metabolic disorders
Gastrointestinal disorders (e.g., Crohn’s, colitis, gastroparesis, or IBD)
Hormone-related disorders
Cancer (hormone-sensitive)(e.g., Breast, Prostate)
Undiagnosed Vaginal bleeding
Cardiovascular conditions
Pancreatitis
Medullary thyroid carcinoma for Family History of MTC
Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
None of the above
Hidden
Eligibility Results
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Ultimate Kickstart
Plan 1
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Rapid Transformation
Plan 2
Hidden
Long-Term Success
Plan 3
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CARE Esthetics La Quinta
78138 Calle Tampico, Suite #100
La Quinta,
CA
92253
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Call Us
(760) 209-5605
Email Us
info@care-estheticslaquinta.com
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